Wednesday, June 16, 2010

Iraq snapshot

Wednesday, June 16, 2010. Chaos and violence continue, a new report released today indicates Iraq is now a failed-state, another report released today explores the continued and widespread practice of Female Genital Mutilation in the KRG, the US Senate explores rural issues effecting veterans care, the US Army announces 11 suicides, and more.

The U.S.-led invasion pushed the country over the brink, making it a failed state. Saddam [Hussein] fled, state institutions collapsed, a power vacuum emerged, the professional classes left, millions were displaced, and sectarian rivalries plunged the country into a well-organized insurgency and a vicious civil war. [. . .] Seven years later, U.S. costs have soared to an estimated $704 billion, none of which was paid for out of Iraqi oil revenues. Instead of a democracy, terrorism soared, a sectarian civil war broke out, oil production plummeted, and public services declined. Tens of thousands of civilians were killed.

The report argues that March 2008-March 2009 was the "Turning Point" (of the "Full-Scale Civil War') and that from March 2009 through March 2010, Iraq has been in a period of "Stasis." This is eveident by the fact that very few of the 4.7 million internal and external refugees have returned to their homes, by the sectarian rivalries on display in the March 7th elections and the aftermath of lethargy which has followed, the corruption and the lack of adequate social services.

The report concludes with a summary of March 2010 in which "weak" is the rating given to the Iraqi police in part due to "infiltration of police ranks by various insurgent groups" The category of leadership was also judged "weak." The report notes that Nouri al-Maliki is expected to use the long-drawn out process of selecting the next prime minister (which Nouri hopes will again be him) by attempting to "leverage his power over both political and judiciary institutions to secure a second term. As the government formation process drags on, the political vacuum and a general atmosphere of uncertainty can be manipulated by various insurgent groups bent on undermining political progress and delegitimizing the Iraqi government by spreading fear and public terror through violent attacks throughout the country." The civil service is judged "weak" while the judiciary is judged "poor" and the report notes, "The heated debate around the legal standing of the Justice and Accountability Commission continued this month, with legal experts raising concern about the lack of a clear distinction between judicial bodies and administrative committees in Iraq. As a judicial body, the impartiality of the Commission has been compromised by the participation of [Ahmed] Chalabi and [Ali] al-Lami in the parliamentary elections for which they were charged to qualify the candidates. This blurring of the lines between political and judicial institutions testifies to the weakness of the Iraqi judicial system and the permeation of corruption throughout all of the national government bodies." Finally, there is the Iraqi military which is graded "moderate."

We may continue with the report later in the week. But it is one of two major reports released today. FfP's report will probably get a bit of attention from policy journals but the other report is lucky to get attention from the wire services. Human Rights Watch released a new report today, "They Took Me and Told Me Nothing: Female Genital Mutilation in Iraqi Kurdistan" (link goes to HTML overview, report is in PDF format). The 80-page report (page 81 is acknowledgements) documents the continued and widespread practice of FGM in the KRG:

For thousands of girls living in Iraqi Kurdistan (northern Iraq), female genital mutilation (FGM), the removal of parts of the female genitalia for non-medical reasons, is a fact of life. FGM is a conventional social practice seen by many as contributing to girls becoming women, being marriageable, as a religious requirement and as part of their identity as Kurds. An irreversible and painful operation usually carried out by older women, FGM, however has immediate and long-lasting consequences for physical, mental, and sexual health.

The report documents not only the continued practice but the refusal by the Kurdistan Regional Government to not only punish the practice but to even acknowledge it. A (weak) bill within the KRG legislative body never advanced and was not open to discussion. When something is passed, there is no evidence that enforcement ever takes place. As with failure to follow through with turning bills into laws and to enforce the laws that do get passed, attempts at long range plans exist as attention-getting press announcements with no follow ups such as the Ministry of Health's boasting in 2009 of "a five-year strategic plan outling a long-term strategy for intervention" which was quickly and quietly dropped.

In addition, the KRG refuses to collect data on the issue. This may be due to their desire to insist that the widespread practice is actually a minority one. The report cites two studies which demonstrate how widespread the practice is in the KRG.

Why FGM?

A number of reasons are given but fear of female sexuality is at the heart of it. Sometimes it's hidden behind claims that girls who don't go through FGM won't be able to be married, sometimes it's more overt with claims that in the 'hot' climate, without FGM, young females wouldn't be able to control their sexual urges or assertions of "purity."

What some may find most disheartening is that this isn't newly emerging. In other words, the women performing the procedure (midwives) and the mothers and aunts having it performed on their family members have usually experienced it themselves and yet still force a new generation to go through the pain and the danger (which can cause severe problems that we'll get to in a minute). Though they also went through the procedure involving a razor and no medication, weeks of bleeding and pain, they turn around and continue it for the next generations. Sirwa tells HRW, "You must think we are monsters." While Sirwa is a victim of the same culture that the young girls are, it's hard to sympathize with those who should know better but continue and foster a brutal and inhumane procedure.

We'll note this section of the report:

Even later in life, women told us that the memory of their cutting, pain, and the blood still overwhelmed them. Shelan B., a 26-year-old woman from Kallar, said that she had a very bad experience andcontinued, "I was seven when I was circumcised. It was me and my cousin. I bled in a waythat was not normal. . . . When I remember what happened, I get emotionally tired." The lack of health care, particularly emergency care, makes FGM -- always unsafe -- apotential death sentence in Kurdistan. When young girls in rural areas, where FGM is mostprevalent, are cut and bleed severely, they are unlikely to have access to life-saving care. Because no official data is kept on deaths associated with FGM -- there is no policy inhospitals of recording whether the cause of death for young girls is related to FGM -- thenumber of girls who have lost their lives due to the practice remains unknown. The risk of infection is likely to increase where midwives use unclean cutting instruments,which is a frequent occurrence in Kurdistan, and when the same instrument is used to cutseveral girls. Since infections are only documented when women seek care, it is difficult toascertain the extent of these complications. Even where women and girls do seek care, theMinistry of Health does not have policies or guidelines to help hospitals or clinics tosystematically document and monitor the health consequences of FGM. Dr. Fattah Hamarahim Fattah explained that the sexual health consequences of FGM includepain during intercourse, low desire for sex, and less pleasure during intercourse. Theselong term effects may surface only when a woman marries because that may be her firstsexual encounter. Pre-marital sex is socially stigmatized in traditional Muslim societies likeIraqi Kurdistan. Dr. Atia al-Salihy, an obstetrics and gynecology specialist in Arbil, noted that women whoundergo FGM suffer psychologically. She said that when they marry, women may begin toremember the assault on their bodies when they were children, with severe consequencesfor their sexual and mental health.

40-year-old Kochar was a young girl when she was brutalized. Even so, she tried to run away repeatedly and was "pinned down by three women" for the assault to be performed. She refused to do the same to her own daughter indicating that it is possible to break the chain. The report notes, "Iraq has signed all key international human rights treaties that protect the rights of women and girls, including the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), the International Covenant on Civil and Political Rights (ICCPR), the International Covenant on Economic, Social and Cultural Rights (ICESCR) and the Convention on the Rights of the Child (CRC). These treaties place responsibility and accountability on the Iraqi government and the Kurdistan Regional Government for any human rights violations that take place in Iraqi Kurdistan, including FGM."

The report has a list of recommendations. Public pressure doesn't make the list; however, it should be noted that the KRG has always been sold as "the other Iraq" and "the safe Iraq." If each marketing attempt (passed off as reporting) on the KRG noted FGM, it would force the government to take action. However, don't expect that to happen. Let's remember that, in its zeal to sell the KRG not all that long ago, Newsweek was insisting that young women being set on fire by their families were doing it to themselves because it was 'cool' and the 'hot' teenage thing to do. In such a climate, it's a bit hard to expect the press to be of much help.

During its interviews with Kurdish officials, Human Rights Watch said the government had downplayed the frequency of the practice, in part because of conerns about the damage the study might have on the international reputation of Kurdistan, which is generally regarded as being more Western and less socially conservative than much of the Middle East.

Young girls and women described how their mothers had taken them to the home of the village midwife, a non-licensed practitioner. They were almost never told in advance what was going to happen to them. When they arrived, the midwife, sometimes with the help of the mother, spread the girl's legs and cut her clitoris with a razor blade. Often, the midwife used the same razor to cut several girls in succession.

Doctors in Iraqi Kurdistan told Human Rights Watch that the most common type of FGM believed to be practiced there is partial or total removal of the clitoris and/or prepuce, also known as clitoridectomy. Health care workers said that an even more invasive procedure was sometimes performed on adult women in hospitals. The practice serves no medical purpose and can lead to serious physical and emotional consequences.

Reuters notes a Mosul car bombing injured two police officers, an armed clash in Mosul with police shooting dead 1 person, a Mosul suicide car bombing which claimed the life of the driver and left fourteen people wounded and a Baghdad roadside bombing which left three people injured. Tang Danlu (Xinhua) adds a Baghdad liquor store bombing injured four people and a Baghdad car bombing which injured one person. Mohammed Al Dulaimy (McClatchy Newspapers) reports 1 Iraqi soldier was shot dead in Mosul. In addition, Lin Li (Xinhua) notes that a Turkish soldier was killed by the PKK on the border between Turkey and Iraq where clashes continue in Sirnak Province (yesterday, another Turkish soldier was killed on the border by the PKK). AFP notes that 3 members of the PKK were killed "overnight" in clashes along the border. BBC News puts the number at 4 killed. We'll note this from "Attacks threaten unusual Turkish outreach to Kurds" (Today's Zaman):

World attention has focused on the nine Turks killed and hundreds detained late last month in the Israeli boarding of a Turkish vessel seeking to break the Gaza blockade. Inside Turkey, fury at the raid has been accompanied by alarm and anger over strikes on army units in the traditionally safer south and north, hundreds of miles from the poor, Kurdish-dominated southeast where the terror fight for autonomy is concentrated.The public outrage and escalating military response appear likely to derail an already faltering government effort to defuse the Kurdish insurgency by granting unprecedented cultural and political freedoms to Turkey's largest minority group.

"Today we will discuss VA health care in rural areas," declared Senator Daniel Akaka this morning calling the Senate Committee on Veterans Affairs to order. "Rural settings are some of the most difficult for VA and other government agencies to deliver care. I beieve, and I know many of my colleagues on this Committee share the view, that we must utilize all the tools at our disposal in order to provice access to care and services for veterans in rural and remote locations."

Before the testimony could start, Chair Akaka explained that the VA had not submitted their prepared statements in time and the VA's Robert Jesse to convey that message.that "the Department's testimony was submitted over 29 hours late." May 19th, OMB also struggled to meet a known deadline when appearing before the Committee. Jesse was on the first panel along with Disabled American Veterans' Adrian Atizado, Veterans Rural Health Advisory Committee's James F. Ahrens and Haywood County Veteran Service Officer Ronald Putnam. The second panel was composed of Yukon's-Kuskokwim Health Corporation and Brig Gen Deborah McManus.

Adrian Atizado noted that 1/4 of the US population lives in rural areas and over 44% of the military recruits serving today are from rural areas; however, only 10% of physicans are practicing in rural areas. This limits their access to health care. This leads to "disparities and differences in health status between rural and urban veterans." Atizado advocated for the expansion of tele-health capabilities. Ronald Putnam stated, "The rural areas of our country have become a sanctuary for many veterans who suffer from Post Traumatic Stress Disorder and other service connected disabilities which adversely affect the veterans." He further noted, "Although a lot of the VA's current efforts to communicate more closely with veterans by utilizing modern media and technology, I want to remind both this Committee and the Veterans Administration that there are still a number of WWII, Korea and Vietnam veterans that have unique education deficiencies and social disconnects that make it extremely hard to receive the information that is being presented on these twenty-first century medians. I will remind this Commitee, the Veterans Administration and all my colleagues that the best communication with these veterans is face-to-face interaction with someone who is knowledgeable, well trained and willing to assist these men and women that we owe such indebtedness to."

On the issue of getting providers to rural areas, raised by Senator Jon Tester, it was pointed out by Ahrens that most of the training centers for veterans providers are in urban areas and that getting the residents into rural areas would likely help that. Tester asked about home dialysis and Dr. Jesse responded that approximately 7% of veterans (apparently of veterans receiving dialysis) get home dialysis. "It's doable," he explained. "It doesn't require sending someone into the home. Even patients and their families can do it." Asked if it is cost-effective, Dr. Jesse replied, "We think it's at least cost-neutral."

What is tele-health? Tele-health -- more commonly spelled "telehealth" -- is diagnosing over the phone, it also includes video-conferencing, counseling, allowing x-rays and other screenings to be interpreted outside the rural area and discussed via a phone conference or 'visit.' Dr. Jesse stated that tele-health programs are currently in 140 of the VA's medical centers and allow "41,000 veteran patients to remain living independently in their own homes."

Senator Mark Begich represents a state which is largely rural: Alaska. We'll note his exchange with the first panel.

Senator Mark Begich: You had made the comment, you're trying to expand these contracts and you used Anchorage as an example and you're working through it. Can you elaborate a little more, what does that mean? And why I say this is because, to be very frank with you, I've heard that on a regular basis. There's one thing that we have is a huge opportunity of medical facilities and then health care services is a great example because the way we manage them up there but also huge facilities both in Fairfield and in Anchorage that I think are under-utilized. But help me understand when you say you're working out a process or you're working through contracts, tell me what that means and what kind of a timetable?

Dr Robert Jesse: I-I-I-I think Mr. Schonhard could speak to that better since he's the one involved in that.

Senator Mark Begich: He's behind you and smiling. So that's --

Dr Robert Jesse: It's Providence --

Senator Mark Begich: If you want to reserve some of your answer, you can.

Dr Robert Jesse: Since you've asked, it's - it's the Providence Health System in Anchorage that they're in the process of developing or negotiating to cover at least the cancer care.

Senator Mark Begich: Let me ask you if I can -- and I'll hold more detail for the next panel -- but let me ask you can you or do you keep data on -- in any state -- how utilization of non-VA facility by VA receipiants -- In other words, do you have data points so if I said to you, "What's the percentage in Montana or Nebrask or in Alaska that take advantage based on proximity and other things?" Do you have such a -- And what kind of services do they receive?

Dr Robert Jesse: Well this is complex because, uhm, there's-there's a couple of terminologies that we need to be clear about. One is what's called "fee care." Fee care by the strict definition means we don't provide the service and we authorize the veteran to go and get it and we pay that bill.That's a small component of what's in broad-encompassing non-VA care which would include both fee care but also uhm, uhm, care that is through contract, through community providers, care that's delivered through contract or other agreements if you will through our academic affiliates.

Senator Mark Begich: Yes.

Dr Robert Jesse: And, uhm, the other is that we don't have a handle on it because we don't really pay for it is care that the veteran themselves choose to get on the outside because many of them do have secondary insurance and/or in addition to Medicare. And we have uh-uh that dual care is a particular challenge to us -- not from the financial side, but from the managing care side. So we have uhm, uhm, the ability to track fee care obviously. We a lot of the contract care -- the ability to roll it up is less robust because some of it is -- it rolls in rather than a flat rate that we're paying on an annual basis. But we can -- we can tell you what that is with at least some level of precision I'm sure.

Senator Mark Begich: Is that something that you can provide to us?

Dr Robert Jesse: I believe so and, without making a promise, I will go back and tell you what granular area we can apply that in.

Senator Mark Begich: Excellent. And as you said, there's fee and then there's contract and --

Dr Robert Jesse: Right. There's a host of vehicles by which we-we --

Senator Mark Begich: The more defined you can do that, the better off.

Dr Robert Jesse: Sure.

Senator Mark Begich: I'd be very interested in that. Let me, if I can, there's been some good testimony on tele-health and in Alaska we use it a great deal not only from a VA perspective but our Travel Consortium which is our Indian Services is a huge piece of the puzzle of how we move through delivering health care in areas where one -- Even a van -- I know, Mr. Ahrens, I know you talk about increasing the vans, but we can't even get a van there. Let alone a plane depending upon weather.Is there, both of you, uhm, clearly have stated, that where rural health centers are located, that where the Office of Rural Health is located, do you think elevating that to a higher level will get some more recognition of the data that needs to be done, the need to understand it better and deliver it better or is the location -- You [Dr. Jesse] were concerned about where it was located in the kind of system where the office is but Mr. Ahrens, I didn't hear you make a comment on that. Do you have any comment in regards to that?

James F. Ahrens: The Office of Rural Health

Senator Mark Begich: Yes.

James F. Ahrens: I think the higher elevation you can give it, the better off we are. And we're slowly getting it staffed -- been a lot of staff changes -- and I think it's got the attention of the Secretary [of the VA] and we ought to keep it right at the highest level we can. It's very important.

Senator Mark Begich: Do you think that where that it's located now -- You know the tele-health issues? I agree with you, if you don't have the data, it's irrelevant. You can spend a lot of time talking about how important it is. We see it in real life in Alaska. But do you think that has anything to do with the level of data necessary? Or is it just two separate issues that need to be addressed? In other words, data collection has its own and then moving this office up higher?

James F. Ahrens: Well -- I think -- Again, keep the office as high as you can. Data collection is very important. We don't even know where veterans are. And we need to know the utilization of their services -- if that's what you're asking me. And we have to have certain data in order to proceed -- If you're running a business how you going to proceed with that if you don't know where your customers are? And so we have to continue to get that. We can't even make some decisions with our committee because we don't know where they are, what disease entity they might have and what services should be placed in those areas. If we knew a little more about that, we'd be better off. So the Office of Rural Health ought to get on that and get it done.

Senator Mark Begich: Let me -- and my time has expired -- the report that you sent up to the Secretary, do you anticipate that to be public or available to us -- at what point, do you think?

James F. Ahrens: As I said, it's under the Secretary's scrutiny. I'd love you -- If I could release it to you today, I would but I can't. It's a public document, it should be available to you.

A thirty minute recess followed due to voting and other issues. When the Committee returned Senator Begich was presiding and informed the second panel that they would each have five minutes for their opening statements and the clocks would indicate when there time was up. He added some levity to the proceedings by following that with, "If you violate that, the floor will release below you." After opening statements, the remaineder of the second panel was approximately twenty-two seconds. We'll grab that tomorrow or Friday to cover one other domestic topic and one topic (lengthy passage from this morning) that British community members asked be included in today's snapshot.

For the month of April, the US Army announced yesterday, they can confirm 4 suicides among active-duty service memberrs with six still being investigated and there are nine ongoing investigations into May deaths. For the reserves, the US Army said there 7 suicides in April and 2 in May with ten more still being investigated. From the press release:

The Army has identified additional crisis intervention resources available to the Army community. Soldiers and families in need of crisis assistance are strongly encouraged to contact Military OneSource or the Defense Center of Excellence for Psychological Health and Traumatic Brain Injury Outreach Center (DCoE). Trained consultants are available from both organizations 24 hours a day, 7 days a week, 365 days a year.

The Military OneSource toll-free number for those residing in the continental United States is 1-800-342-9647, the Military One Source Web site can be found at http://www.militaryonesource.com . Overseas personnel should refer to the Military OneSource Web site for dialing instructions for their specific location

The Defense Center for Excellence for Psychological Health and Traumatic Brain Injury (DCoE) Outreach Center can be contacted at 1-866-966-1020, and at http://www.dcoe.health.mil.

Suicide prevention training resources for Army families can be accessed at http://www.armyg1.army.mil/hr/suicide/training_sub.asp?sub_cat=20 (requires Army Knowledge Online access to download materials) .

One of the most striking elements of the debate was the behavior of Ed Miliband, who left no doubt at all that he is fighting, hard, to beat his own brother and win this contest. He said he wanted to be "prime minister" in his introduction and repeatedly attempted to interrupt David Miliband, on one occasion saying Labour's fortunes were down to "more fundamental" issues than those which were being discussed. He seemed to have had a haircut, wore a smart pink tie and peered straight into the camera, Nick Clegg style, as much as he could.

I'll go with Macintyre, Ed wants it. I was wrong. (As disclosed before, I know David and Ed Miliband. And I've noted before -- wrongly -- I didn't think Ed was serious about wanting the post.) Though David and Ed are not the only two competing for the top post (Diane Abbott, Ed Balls and Andy Burnham are also competing), the 'battling' brothers are garnering the bulk of the press attention. Sify offers "Miliband brothers bitching for Labour leadership." The Sun goes with "Brother of all battles is on" for Tom Newton Dunn's article:

THE Miliband brothers are waging a bitching war against each other as they battle for the Labour leadership, another rival has revealed.Ed Miliband's supporters have been slagging off his brother David's "eccentric personality".And David's fans are mocking Ed's "dodgy decision-making", according to former Education Secretary Ed Balls, who is also in the running.

The biggest area of contention was the Iraq war. Ed Miliband continued his attempt to exploit the issue by highlighting his newly-discovered opposition. Ed Balls also voiced his doubts, but to his credit pointed out that had he been an MP at the time he would have voted with the Government and for the war. David Miliband rightly pointed out that Labour's defeat had next to nothing to do with a war that did not stop Labour being re-elected in 2005. The best response though came from Andy Burnham, who stood by the decision, in particular because it strengthened our hand in negotiating with Iran: "We should continue to make a principled argument for what we did and why we did it."

Ed Miliband came under attack last night when his rivals for the Labour leadership hit out at any attempts to "rewrite history" on the Iraq war.Ed Miliband, David Miliband, Diane Abbott, Ed Balls and Andy Burnham appeared in the first televised hustings which are due to run into August. Some of the candidates turned on the younger of the two Miliband brothers who in the first few weeks of his candidacy has made much of his opposition to the war. Though he was not an MP at the time of the invasion, Ed Miliband has said he thought UN weapons inspectors should have been given more time.Ed Miliband told the studio audience of lost Labour voters at BBC2's Newsnight hustings that the broader lesson he drew from Iraq was that war should always be the last resort, to which his brother David Miliband, the shadow foreign secretary, said: "The idea that anyone on this panel doesn't think that war is the last resort doesn't do justice the substance of this issue."

As always, I would hate to be Amitbah Pal. I would hate to be him. The Iraq War did not vanish from the British landscape -- despite what a lot of gas bags want to tell you.

About Me

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